The Center At Advocate
Inspection history, citations, penalties and survey trends for this long-term care facility in East Boston, Massachusetts.
- Location
- 111 Orient Avenue, East Boston, Massachusetts 02128
- CMS Provider Number
- 225413
- Inspections on file
- 24
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Center At Advocate during CMS and state inspections, most recent first.
Nursing staff initiated CPR on a resident with documented DNR/DNI status after a choking event, due to incorrect verification of code status in the electronic medical record. The resident's advanced directives were not properly identified or communicated during the emergency, resulting in resuscitative efforts that were contrary to the resident's wishes.
Nursing staff did not communicate wound care recommendations from consulting clinicians to attending physicians and failed to consistently monitor and document the progress of wounds for two residents with complex pressure injuries. Despite facility policy requiring physician review of recommendations and weekly wound assessments, there was no evidence that new treatment orders were obtained or that wounds were measured and tracked as required.
A resident admitted with two Stage 2 pressure injuries did not have Enhanced Barrier Precautions (EBP) implemented as required. Staff failed to notify the IP, obtain a physician's order, or provide appropriate signage and PPE. Direct care was provided without proper infection control measures, and staff interviews revealed a lack of awareness regarding the need for EBP.
A resident with severe cognitive impairment repeatedly complained to staff about a roommate's loud television at night, but staff did not file a formal grievance or document the resolution as required by facility policy. Although the complaint was reported to the Unit Manager and discussed with the roommate, the grievance was not entered into the grievance log, and the Nursing Home Administrator could not account for the lack of documentation.
A resident with a pacemaker did not have a comprehensive, individualized care plan addressing the monitoring and care of the device. The care plan lacked specific details, and physician orders were missing critical information such as the pacemaker setting rate, serial number, and cardiologist contact. Nursing staff and the DON confirmed that this information should have been included to guide appropriate care.
A resident with severe cognitive impairment and on anticoagulant therapy did not receive a physician-ordered weekly skin check, and visible bruising on the right arm and forearm went unreported and undocumented for three days. Staff interviews confirmed that required skin assessments and documentation were not completed as per facility policy and medical orders.
A resident requiring substantial assistance with self-care was repeatedly observed with facial hair despite expressing a desire for its removal and having no documented refusals of care. Staff interviews and documentation confirmed the resident needed help with grooming, but assistance with shaving was not provided as required by facility policy.
Two residents at risk for or with existing pressure ulcers did not receive care consistent with physician orders, as staff failed to maintain prescribed air mattress settings. Despite clear orders and care plans specifying required settings and shift checks, mattresses were observed at incorrect settings, and staff interviews confirmed the lapses in following protocol.
A resident with PTSD, vascular dementia, and anxiety did not have a trauma-informed care plan with identified triggers, as required by facility policy. Despite staff expectations that trauma assessments and individualized care plans would be developed collaboratively, the resident's record lacked documentation of such a plan or interventions addressing trauma triggers.
A medication cart was observed unlocked and unattended on one unit, allowing access to drugs and biologicals. A nurse returned and locked the cart, confirming it should have been secured when not attended. The DON stated that the expectation is for medication carts to be locked when unattended.
Staff on two units left medication carts unattended with open laptops displaying resident MARs and names, allowing staff and residents passing by to view confidential information. Nurses involved acknowledged the screens should have been closed, and the DON confirmed the expectation for privacy of electronic medical records.
A resident who was totally dependent on staff for bed mobility and incontinence care was left unattended on their side while a CNA left the room to get supplies. During this time, the resident fell from the bed, striking a concrete ledge and sustaining multiple fractures and a scalp abrasion, requiring hospitalization. The care plan and therapy assessments documented the resident's need for total assistance, but adequate supervision and support were not provided during the incident.
Three residents were affected when the facility failed to properly assess, document, and implement bed rail use according to physician orders and informed consent. One resident had bed rails installed without a completed assessment and with a physician order for grab bars instead. Two other residents, after room changes, did not have bed rails reinstalled on their new beds despite having consent and orders for them, due to a breakdown in communication between nursing and maintenance.
A resident with complex medical needs missed two consecutive doses of scheduled hydromorphone for pain because nursing staff could not access the Emergency Medication Dispensing System (EMDS) due to a lockout error. The agency nurse on duty lacked EMDS access, and only the DON or ADON could override the system, but neither was available. The pharmacy confirmed that alternative medications were available and that administrative staff could have resolved the issue if contacted.
A resident who was totally dependent on staff for all ADLs, including transfers, repositioning, and toileting, had significant gaps in CNA documentation on ADL Flow Sheets over a 15-day period. Despite facility policy and staff interviews confirming the requirement for timely and accurate documentation, many shifts had incomplete records for this resident.
The facility did not ensure that residents and their representatives were invited to participate in interdisciplinary care plan meetings following comprehensive and quarterly MDS assessments. For three residents with varying degrees of cognitive impairment and complex medical histories, there was no documentation of invitations or attendance at care plan meetings, and staff interviews confirmed lapses in the process for scheduling and notifying residents and families.
A resident with multiple medical conditions and a physician's order for bed rails was not provided with the requested bed rails for safety and repositioning. The facility failed to consult the resident or family about bed rail use, and staff did not complete the required assessment or obtain consent, resulting in the resident's request not being addressed.
A resident with a history of urinary retention missed a scheduled urology consult because the nursing staff overlooked the appointment in the hospital discharge summary, and transportation was not arranged. The Patient Coordinator was not informed, and the admitting nurse and Nurse Practitioner were unaware of the appointment, leading to the oversight.
The facility failed to provide adequate behavioral health services, leading to a resident's suicide attempt after expressing suicidal ideation. Despite having a behavioral health service agreement, the facility did not develop a care plan or implement safety interventions for the resident. Interviews revealed a lack of clarity regarding the provision of talk therapy and behavioral health services, with the Psychiatric NP focusing only on medication management.
The facility failed to provide necessary behavioral health services for residents with a history of suicidal ideation and depression. A resident with bipolar disorder and depression attempted suicide due to inadequate monitoring and intervention. Another resident expressed suicidal thoughts, but the facility did not address these with psychiatric or social services. Two other residents showed worsening depression, but their care plans were not updated to reflect this. The facility's actions highlight a deficiency in addressing the mental health needs of its residents.
A resident with a history of mental disorders and suicidal ideation was not provided with appropriate treatment and services, leading to an attempted suicide. Despite expressing suicidal thoughts and distress, the facility failed to update the care plan or implement necessary interventions. The resident's safety concerns were not adequately addressed, resulting in a serious incident.
A resident with a history of mental health issues and suicidal ideation did not receive adequate social services in a LTC facility, leading to an attempted suicide. Despite severe depression and multiple expressions of suicidal thoughts, the facility failed to provide necessary social support and did not update the care plan to address the resident's SI. The resident attempted suicide and was hospitalized after being found with a plastic bag tied around their neck.
The facility failed to prevent a decline in range of motion for a resident who developed hand contractures without appropriate assessment or referral to therapy. Another resident did not receive a prescribed left hand resting splint, with staff using an inappropriate substitute and failing to document the resident's use or refusal of the splint. These deficiencies indicate lapses in communication and adherence to care protocols.
The facility did not complete annual reviews for five employees, as revealed during a surveyor's review of personnel records. The DON acknowledged responsibility for the oversight and confirmed that no reviews were conducted in the past year.
The facility failed to designate a qualified infection preventionist for its infection prevention and control program. The DON has been covering this role without the required certification since April 2024. Interviews with the Medical Director, Administrator, and Regional Nurse confirmed the absence of a designated infection preventionist.
A resident with severe cognitive impairment was diagnosed with chickenpox, but the facility failed to maintain proper airborne precautions. The resident was observed outside their room without staff intervention, and staff entered the room without appropriate PPE. The facility also did not conduct adequate infection control surveillance or report the communicable disease to health authorities in a timely manner.
The facility failed to properly label and store medications, with several instances of opened and undated medications found in medication carts. Additionally, medication carts and cabinets were left unlocked and unattended, contrary to facility policy. Nurses and the DON acknowledged these lapses in medication management and security.
The facility failed to provide proper orientation to agency nursing staff, leading to medication administration errors. A nurse on his first day attempted to administer incorrect medications due to a lack of orientation. The facility's policy requires orientation before staff contact with residents, but records showed incomplete or missing orientation checklists for agency nurses.
The facility failed to develop comprehensive care plans for two residents, one with suicidal ideation and another with a chewing behavior posing a choking risk. Despite a history of suicidal ideation, a resident's care plan lacked interventions for safety, as confirmed by staff interviews. Another resident's care plan did not address chewing behaviors or interventions to prevent choking, despite staff acknowledging the risk. These deficiencies highlight a failure to adhere to the facility's policy on person-centered care plans.
A resident with a history of bipolar disorder, depression, and suicidal ideation was admitted to a facility, but the care plan was not updated to address the risk of suicide. Despite expressing a desire to die and being readmitted after hospitalization for suicidal ideation, the care plan remained unchanged. Interviews with staff confirmed the need for an updated care plan with safety measures.
A resident with bipolar disorder and depression was not provided necessary assistance with personal hygiene, specifically facial hair removal, despite expressing a desire for help. Facility staff failed to adhere to the care plan requiring extensive assistance with ADLs, and no documentation indicated the resident refused care.
A medication error rate of 14.29% was observed in an LTC facility when two nurses made errors affecting two residents. One resident received an incorrect dosage of metoprolol and an unauthorized substitute for a dietary supplement due to a nurse's unfamiliarity with the facility's procedures. Another resident received incorrect dosages of olanzapine and Zoloft because the nurse relied on the medication card instead of the physician's order in the computer.
A nurse unfamiliar with the facility prepared to administer double the prescribed dose of metoprolol to a resident. The resident's order was for 12.5 mg twice daily, but the nurse prepared 25 mg due to a lack of orientation to the facility's medication administration process. The error was caught by a surveyor, and the correct dosage was clarified by another nurse.
A resident with cognitive impairments and a history of hoarding hazardous items, such as razors, was not adequately monitored by the facility. Despite incidents of hoarding and threats of harm, interventions were delayed, and safety checks were not implemented until after further incidents occurred.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed multiple times with the catheter drainage bag and tubing touching the floor, contrary to professional standards. Despite staff awareness that the drainage system should not contact the floor, the facility failed to consistently prevent this, contributing to the deficiency.
A facility failed to provide necessary emergency equipment for a resident requiring dialysis. Despite orders and care plans indicating that clamps should be at the bedside for emergency use, observations confirmed their absence. Interviews with staff, including a nurse and the DON, acknowledged that the equipment should have been present, indicating a lapse in care standards.
A facility failed to develop a trauma-informed care plan for a resident with PTSD, despite the resident's severe cognitive impairment and active PTSD diagnosis. The facility's policy requires culturally competent care that addresses trauma survivors' needs, but no such plan was found in the resident's medical record. The DON confirmed that social services are responsible for creating PTSD care plans.
A resident with severe cognitive impairment was observed walking in the hallway with ripped sweatpants that exposed their buttocks. Despite requiring substantial assistance with dressing, staff did not intervene to ensure the resident's dignity was maintained. The Director of Nursing acknowledged the oversight.
The facility failed to maintain a homelike environment by not addressing a chirping fire alarm in a resident's room. The issue persisted over three days, and the Maintenance Director was unaware due to a lack of communication, as he relies on maintenance logbooks or direct calls to be informed of such issues.
A resident with severe cognitive impairment and a history of mental health issues made homicidal threats towards their roommate, leading to involuntary hospitalization. The facility failed to report the incident to the state agency as required by their abuse and neglect policy. The DON was unaware of the reporting lapse.
A resident with severe cognitive impairment and a history of mental health issues threatened their roommate, leading to emergency removal from the facility. The incident was not reported to the state agency as required, and the DON was unaware of this oversight.
A facility failed to update the PASARR Level II for a resident admitted with mental health diagnoses, including bipolar disorder and schizoaffective disorder. The resident's initial PASARR allowed for a 7-day Provisional Emergency admission, but the facility did not complete an additional review when the stay exceeded this period.
The facility failed to provide the correct therapeutic diets for two residents with severe cognitive impairment and swallowing difficulties. Despite orders for ground texture diets, both residents were observed consuming regular textured foods. Staff interviews revealed inconsistencies in understanding and implementing dietary orders, and meal trays were not properly checked to ensure compliance.
The facility failed to provide necessary behavioral health services to 6 out of 68 residents identified with depression disorder. Despite the facility's assessment claiming the ability to manage psychiatric symptoms and implement interventions, these residents did not receive services after a decreased mood was identified through the PHQ-9.
A resident with a left hand contracture was not wearing the prescribed resting hand splint, despite documentation indicating otherwise. Observations showed the resident without the splint, and staff applied an incorrect device. The resident reported staff did not assist with the splint, and there was no documentation of refusal.
A resident with dementia, stroke, and depression was found multiple times with an inaccessible call light, lying on the floor behind the bed, despite requiring assistance with daily activities. The resident confirmed the inability to call for help, and the fall care plan included an intervention to ensure the call light was within reach. A unit manager acknowledged that call lights should be accessible for all residents.
Failure to Honor Resident DNR/DNI Status During Emergency Response
Penalty
Summary
Nursing staff failed to honor a resident's right to self-determination regarding advanced directives when they initiated CPR on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. The resident, who had diagnoses including schizoaffective disorder, diabetes mellitus, dysphagia, and GERD, had clear documentation in the medical record, hospital discharge summaries, and a signed MOLST form indicating DNR/DNI status. The resident's code status had also been discussed with the health care agent and was reflected in the physician's orders. On the day of the incident, the resident experienced a choking event and, after the Heimlich maneuver was performed, became unresponsive and was found without a pulse. Nursing staff, uncertain of the resident's code status, checked the electronic medical record and incorrectly determined the resident was a full code. As a result, a code blue was called and CPR was initiated by two nurses until EMS arrived. It was only after EMS took over that the correct MOLST form was located, confirming the resident's DNR/DNI status, and CPR was stopped. Interviews with staff revealed that the advanced directives and MOLST form were not properly identified or communicated at the time of the emergency. The Director of Social Services acknowledged missing the advanced directives upon admission, and the Director of Nursing stated that staff are expected to physically verify the MOLST form during emergencies. The failure to accurately verify and honor the resident's advanced directives led to the initiation of unwanted resuscitative efforts.
Failure to Communicate Wound Care Recommendations and Monitor Wound Progress
Penalty
Summary
Nursing staff failed to ensure that care and services provided to residents with wounds met professional standards of quality. For two of three sampled residents who received wound care services, the facility did not notify the attending physician of recommendations made by wound care clinicians, nor did they adequately monitor and assess the residents' wounds to determine if the areas were improving or deteriorating. Facility policy required that all recommendations from consulting providers, such as wound clinics, be reviewed with the attending physician for approval or denial, and that the effectiveness of interventions be monitored through ongoing assessment and documentation in the medical record. One resident with a history of schizophrenia, bipolar disorder, diabetes with neuropathy, and a non-healing left hip surgical wound that developed into a Stage IV pressure injury, was seen monthly at an outpatient wound clinic. The clinic provided specific treatment recommendations, including wound care orders and interventions for pressure injury management. However, there was no documentation that these recommendations were reviewed with or brought to the attention of the attending physician, nor was there evidence that physician orders were obtained for new treatments. Additionally, nursing staff failed to document measurements or monitor the progress of the resident's wounds in weekly skin assessments, nurse progress notes, or treatment administration records, despite facility policy and staff statements that such monitoring was required. Another resident admitted with dementia, repeated falls, and depression, had bilateral unstageable pressure injuries to the heels. The in-house wound care specialist recommended an air mattress for pressure redistribution, but there was no documentation that this recommendation was communicated to the attending physician, and the resident did not have an air mattress in place. Furthermore, after initial assessment and staging of the heel wounds, subsequent weekly skin assessments and nursing documentation failed to record observations, measurements, or monitoring of the wounds' progress. Interviews with facility staff confirmed that recommendations from wound care providers should be reviewed with the attending physician and that weekly wound measurements were expected but not completed.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Injuries
Penalty
Summary
Nursing staff failed to implement and follow Enhanced Barrier Precautions (EBP) for a resident admitted with two Stage 2 pressure injuries, as required by the facility's infection control policy. The Infection Preventionist (IP) was not notified of the resident's wounds upon admission, and a physician's order for EBP was not obtained until after the issue was identified by a surveyor. During observations, there was no signage indicating precautions outside the resident's room, and no personal protective equipment (PPE) was available or used by staff providing direct care, except for gloves. Interviews with staff revealed a lack of awareness regarding the resident's need for EBP, with both CNAs and a nurse stating they were unaware of any required precautions or the presence of wounds that necessitated such measures. The Director of Nursing (DON) confirmed that residents with wounds should be placed on EBP immediately and reported to both the DON and IP, but this protocol was not followed in this case.
Failure to File and Resolve Resident Grievance Regarding Roommate Disturbance
Penalty
Summary
The facility failed to ensure that grievances were filed and resolved in a timely manner for one resident. The resident, who had diagnoses including major depressive disorder and mild neurocognitive disorder with severely impaired cognition, repeatedly complained to staff about a roommate's television being too loud at night, which interfered with sleep. Despite these complaints being documented in clinical progress notes, there was no evidence that a formal grievance was filed or that the grievance process was followed according to facility policy. Nurse staff acknowledged receiving the complaints and reported speaking to the roommate and notifying the Unit Manager, but did not initiate a grievance form or document a resolution in the grievance log. The Nursing Home Administrator confirmed that grievances should be documented and resolved promptly, but could not explain why this was not done in the resident's case. The facility's grievance log did not contain any record of the resident's complaints or their resolution.
Failure to Develop Comprehensive Care Plan for Pacemaker Management
Penalty
Summary
The facility failed to develop a comprehensive, individualized care plan for a resident with a pacemaker. The care plan in place identified the presence of a pacemaker and associated risks, such as activity intolerance, pacemaker failure, and altered cardiac output, and included an intervention to monitor vital signs and notify the physician of significant abnormalities. However, the care plan lacked specific details and individualized interventions related to the monitoring and care of the pacemaker. Record review showed that the resident's physician orders did not include essential information such as the pacemaker setting rate, serial number, or cardiologist contact details. Interviews with nursing staff and the Director of Nursing confirmed that this information should have been present in the physician orders to guide care. The absence of these details meant that staff did not have the necessary information to properly monitor and respond to the resident's cardiac needs.
Failure to Complete Physician-Ordered Skin Checks and Timely Identification of Bruising
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for one resident with severe cognitive impairment and a history of anticoagulant use. Specifically, the facility did not complete a physician-ordered weekly skin check and did not identify or document bruising on the resident's right arm and forearm for three days. Observations by the surveyor over three consecutive days revealed visible bruising that was not recorded in the resident's weekly skin evaluations or nursing progress notes. The resident's care plan required daily skin inspections and prompt reporting of abnormalities, especially due to the increased risk of bleeding associated with anticoagulant therapy. Interviews with staff confirmed that CNAs are expected to report any observed bruising to nurses immediately, and nurses are responsible for documenting such findings in the medical record. However, the CNA who first noticed the bruise did not report it, and the required weekly skin assessment was not completed as ordered. The Director of Nursing and other nursing staff acknowledged that the skin checks and documentation should have occurred according to policy and physician orders, but these actions were not carried out for this resident.
Failure to Assist Dependent Resident with Facial Hair Removal
Penalty
Summary
Nursing staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required substantial to maximal help with self-care. The resident, who had a history of multiple fractures, malignant neoplasm, and a contracture of the right hand, was observed on multiple occasions over several days with facial hair on the upper lip, chin, and neck. The resident reported normally not having facial hair and expressed a desire for its removal but was unable to perform this task independently and required staff assistance. Facility policy required that residents unable to perform ADLs receive the necessary services to maintain grooming and personal hygiene. Documentation indicated the resident needed significant help with personal hygiene, including shaving. There was no evidence in the nursing progress notes that the resident refused care, and staff interviews confirmed that shaving should be provided during routine care with refusals documented. However, the resident continued to have facial hair present, indicating that assistance with shaving was not provided as required.
Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, for two residents with significant risk factors and existing wounds, staff did not follow physician orders regarding the settings of air mattresses, which are critical for pressure ulcer prevention and management. Observations revealed that one resident's air mattress was consistently set at 125 lbs, despite a physician order and care plan specifying a setting of 150 lbs. Another resident's air mattress was observed set at 340 lbs, while the physician order and care plan required a setting of 160 lbs. In both cases, the medical records, care plans, and physician orders clearly documented the required settings and the need for staff to check the mattress function and settings every shift. Interviews with nursing staff and the Director of Nursing confirmed that nurses are responsible for checking and maintaining the correct air mattress settings each shift, as per physician orders. However, staff acknowledged that the mattresses were not set according to the prescribed settings. The facility's policy also required licensed nurses to check powered support surfaces for proper functioning and inflation each shift and as needed. Despite these requirements, the observed discrepancies in mattress settings for both residents demonstrated a failure to follow established protocols and physician directives for pressure ulcer prevention and care.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for one resident with a documented history of trauma, specifically Post-Traumatic Stress Disorder (PTSD), vascular dementia, and anxiety. Despite the facility's policy requiring individualized care plans that identify and address trauma triggers, record review showed that the resident's medical record did not include a care plan for PTSD or any identified triggers. The most recent Minimum Data Set (MDS) assessment confirmed the resident had moderate cognitive impairment and an active diagnosis of PTSD, yet no trauma-specific interventions or trigger identification were documented in the care plan. Interviews with facility staff, including a nurse, unit manager, and the administrator, revealed an expectation that trauma assessments and care plans, including trigger identification, should be completed collaboratively by the care team, with the social worker initiating the process. However, the absence of a trauma-informed care plan for the resident indicated a breakdown in this process. The social worker responsible for these assessments was not available for interview, and no evidence was found in the record to show that the required trauma-informed interventions were developed or implemented.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart was found unlocked and unattended on the 2 West unit during a surveyor's observation. The surveyor was able to open and access the cart without staff present. Shortly after, a nurse returned, closed, and locked the cart, acknowledging that it should have been secured when unattended. The Director of Nursing confirmed in an interview that the facility's expectation is for medication carts to be locked when not attended. No specific residents or patient medical histories were mentioned in relation to this incident.
Unattended Laptops Displaying Resident Medical Records
Penalty
Summary
Surveyors observed that on two separate resident units, staff left medication carts unattended with laptop computers open and displaying resident-identifiable information, specifically the Medication Administration Record (MAR) and resident names. On the 3 [NAME] unit, a nurse left the medication cart and laptop unattended while searching for medications, during which time several staff and two residents passed by and could view the confidential information on the screen. The nurse later acknowledged forgetting to close the laptop screen and confirmed that it should be closed when unattended. Similarly, on the 2 [NAME] unit, a nurse left the medication cart and open laptop unattended, with the screen visible to others in the corridor. Upon returning, the nurse closed the laptop and stated that it should not be left open and visible. The Director of Nursing confirmed that the expectation is for laptop screens displaying resident medical records to be covered or in a private setting when unattended.
Resident Left Unattended During Care Results in Fall and Multiple Fractures
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for bed mobility, repositioning, and incontinence care, was left unattended during care. The resident had significant medical conditions, including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. The care plan and therapy assessments indicated the resident required total assistance for all activities of daily living, including bed mobility and repositioning, and was at risk for slipping or tilting to one side if not properly supported. On the night of the incident, the resident activated the call light and requested to be changed. A nurse responded and informed a CNA, who then entered the resident's room, asked what was needed, and left the resident on their side to retrieve supplies for incontinence care. The CNA reported being out of the room for approximately 2-3 minutes. When the CNA returned, the resident was found on the floor, having fallen from the bed. There was no bed rail in place to assist the resident in maintaining position, and the bed was positioned near a concrete ledge under the window, which the resident struck during the fall. The resident sustained multiple injuries, including a left scalp abrasion, fractures of the left superior and inferior pubic ramus, left scapula, and left clavicle, and required hospitalization for six days. Interviews with staff confirmed the resident's total dependence for mobility and the need for careful repositioning. The facility's policy required immediate interventions and corrective actions to prevent recurrence, but the necessary supervision and assistance were not provided at the time of the incident.
Failure to Assess, Document, and Provide Bed Rails per Physician Orders and Resident Consent
Penalty
Summary
The facility failed to ensure proper assessment, documentation, and implementation of bed rail use for three residents who were capable of making their own decisions. For one resident, although informed consent for bilateral quarter bed rails was obtained, the physician's order specified two grab bars, not bed rails, and the required bed rail assessment form was left blank. Despite this, bilateral quarter bed rails were observed in use for this resident. For two other residents, both had provided informed consent and had physician's orders and assessments supporting the use of bed rails. However, after these residents underwent room changes, bed rails were not installed on their new beds as per their orders. Both residents reported previously having bed rails and using them for bed mobility, but were left without them following the room change. The maintenance director confirmed that he was not informed of the need to reinstall bed rails after the room changes, and the process for communication between nursing and maintenance regarding bed rail installation was not followed.
Failure to Administer Scheduled Pain Medication Due to EMDS Access Issues
Penalty
Summary
A deficiency occurred when a resident with a history of multiple back surgeries, diabetes mellitus, bipolar disorder, and acute on chronic pain did not receive two consecutive scheduled doses of hydromorphone, a narcotic pain medication, as ordered by their physician. The medication was to be administered every four hours for pain, but the 6:00 P.M. and 10:00 P.M. doses were missed. The omission was due to nursing staff being unable to access the facility's Emergency Medication Dispensing System (EMDS), which requires a security code for medication retrieval. On the evening in question, an agency nurse assigned to the resident did not have access to the EMDS. Another nurse attempted to assist but encountered an error code indicating insufficient medication, which locked the system. Only the DON or ADON had administrative access to override the EMDS, but neither was available on-site to resolve the issue. As a result, the resident's pain medication was not administered as scheduled. Interviews revealed that the pharmacy representative confirmed both the DON and ADON could override the EMDS and that alternative medications were available. The pharmacy also indicated that if the original order had been placed as a STAT order, the needed doses could have been delivered. The DON stated that staff are expected to order medications timely and to contact the pharmacy for assistance if access issues arise, but it was unclear if this protocol was followed during the incident.
Incomplete ADL Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who required total assistance with activities of daily living (ADLs) due to multiple diagnoses, including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. According to the resident's care plan and Minimum Data Set (MDS) assessment, the resident was totally dependent on staff for all ADLs, including transfers with a mechanical lift, repositioning, and toileting/incontinent care. A review of the resident's ADL Flow Sheets, which were to be completed daily by CNAs, revealed that documentation was frequently left blank across all shifts over a 15-day period. Specifically, the flow sheets were incomplete for 10 out of 15 days on the day shift, 11 out of 15 days on the evening shift, and 13 out of 15 days on the night shift. Interviews with staff, including a CNA, the Unit Manager, and the DON, confirmed that ADL documentation was required to be completed by the end of each shift and in a timely and accurate manner, as outlined in facility policy.
Failure to Involve Residents in Person-Centered Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their legal representatives participated in the development and implementation of person-centered care plans for three of five sampled residents. Specifically, after the completion of comprehensive and quarterly Minimum Data Set (MDS) assessments, there was no evidence that residents or their representatives were invited to attend interdisciplinary care plan meetings as required by facility policy. For example, one resident with a history of multiple back surgeries, diabetes, bipolar disorder, and chronic pain, who was cognitively intact, reported never being invited to a care plan meeting, and there was no documentation of such meetings in the medical record. Another resident with moderate cognitive impairment and diagnoses including atrial fibrillation and depression also had no documentation of being invited or attending a care plan meeting after their annual MDS. A third resident with anemia, cirrhosis, diabetes, and a history of falls, and moderate cognitive impairment, similarly had no evidence of being scheduled for or invited to a care plan meeting. Interviews with facility staff, including the Director of Social Services, MDS Nurse, and Director of Nursing, confirmed that the process for inviting residents and their representatives to care plan meetings was not consistently followed. Staff acknowledged that it was the facility's expectation for all residents and families to be invited to these meetings, but could not provide documentation or explanation for the missed invitations and meetings for the affected residents. The deficiency was identified through record review and staff and resident interviews, which revealed a lack of compliance with both facility policy and regulatory requirements regarding resident participation in care planning.
Failure to Provide Requested Bed Rails and Consult Resident
Penalty
Summary
A deficiency occurred when a resident who was alert, oriented, and his or her own decision maker, requested bed rails for repositioning and safety but was not provided with them. The resident had a physician's order for two quarter bed rails and a medical history including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. Despite the physician's order and the resident's expressed preference, the facility did not consult the resident regarding the use of bed rails, and the bed rails were not installed during the resident's stay. Interviews revealed that neither the resident nor the family were consulted about the bed rails, and staff members, including the nurse responsible for the bed rail assessment, did not recall completing the necessary assessment or obtaining consent. The Director of Nursing and Nurse Manager were unaware that the resident had not been consulted, and the Director of Rehabilitation did not recall assessing the resident for bed rail use. Facility policy required assessment and consent for bed rails upon admission, but this process was not followed, resulting in the resident's request not being addressed.
Missed Urology Consult Due to Oversight
Penalty
Summary
The facility failed to ensure that nursing care and services met professional standards of quality when a resident missed a scheduled urology consult appointment. The resident, who had a history of cognitive decline, chronic obstructive pulmonary disease, anxiety, depression, renal cancer, and urinary retention, was admitted to the facility with a hospital discharge summary indicating a need for an outpatient urology consult. Despite this, the appointment was overlooked by the nursing staff, and transportation was not arranged, resulting in the resident missing the consult. Interviews revealed that the Patient Coordinator/Medical Records Assistant did not receive information about the need for transportation, and the nurse responsible for admitting the resident was unaware of the scheduled appointment. The Nurse Practitioner also missed the fact that the resident did not attend the appointment. The Director of Nurses confirmed that the facility's expectation was for nursing staff to review hospital discharge paperwork and notify the Patient Coordinator for scheduling appointments, which did not occur in this case.
Failure to Provide Adequate Behavioral Health Services
Penalty
Summary
The facility failed to ensure adequate behavioral health services for residents with mental health disorders, specifically for Resident #192, who attempted suicide after expressing suicidal ideation. The facility's administration did not provide appropriate behavioral health services for seven residents identified with depression, despite using the PHQ-9 tool to measure depression. The facility's assessment indicated it could manage psychiatric symptoms and provide interventions for residents with mental health needs, but this was not effectively implemented. Resident #192, admitted with bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, expressed suicidal ideation upon admission and during a hospital stay. Despite these indications, the facility did not develop a care plan or implement safety interventions for the resident. The clinical record showed no changes to the resident's plan of care or notification to the physician after expressing suicidal ideation. The resident attempted suicide by placing a bag over their head and was subsequently sent to the hospital. Interviews with facility staff revealed a lack of clarity and communication regarding the provision of behavioral health services. The Psychiatric Nurse Practitioner (NP) focused on medication management and did not provide talk therapy, which was assumed to be provided by social workers. The Administrator and Director of Nursing were unaware of the NP's limited role and the lack of talk therapy services. The facility's behavioral health contract services did not meet expectations, and there was no evidence of adequate support for residents' behavioral health needs.
Failure to Provide Behavioral Health Services for Residents with Suicidal Ideation and Depression
Penalty
Summary
The facility failed to provide necessary behavioral health services for four residents with a history of suicidal ideation and/or depression. Resident #192, who had a history of bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, expressed suicidal ideation upon admission. Despite this, the facility did not develop a care plan addressing the resident's suicidal ideation. The resident was found with a plastic bag tied around their head in an attempted suicide, indicating a lack of appropriate monitoring and intervention. Resident #91, diagnosed with major depressive disorder, schizoaffective disorder, and dementia, expressed suicidal ideation shortly after admission. The facility's records did not show that the resident's suicidal ideation was addressed by psychiatric or social services. The care plan for this resident lacked specific interventions for suicidal ideation, and there was no evidence of follow-up or monitoring after the initial expression of suicidal thoughts. Residents #64 and #73, both admitted with depression, showed increasing levels of depression as indicated by their PHQ-9 scores. However, the facility failed to provide additional behavioral health services or update their care plans to address the worsening depression. The facility's lack of timely and appropriate behavioral health interventions for these residents highlights a significant deficiency in meeting the mental health needs of its residents.
Failure to Address Suicidal Ideation in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a known history of mental disorders, suicidal ideation, and adjustment difficulty. The resident, admitted in December 2023, had diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Despite the resident's history and vocalization of suicidal ideation, the facility did not develop or update a care plan addressing these issues, leading to an attempted suicide. Upon admission, the resident's hospital discharge paperwork indicated suicidal ideation, yet the facility's care plan did not include interventions related to the resident's safety or history of suicidal ideation. The resident expressed suicidal thoughts again on January 8, 2024, but no changes were made to the care plan, and the physician was not notified. The resident was later sent to the hospital for a planned procedure and returned with a report of suicidal ideation, but the facility still did not update the care plan. On February 16, 2024, the resident attempted suicide by placing a plastic bag over their head. This incident occurred after the resident had been expressing distress and suicidal ideation, which were not adequately addressed by the facility. Interviews with staff revealed a lack of communication and failure to implement necessary interventions, such as increased monitoring or moving the resident closer to the nursing station, despite the resident's known risk factors.
Failure to Provide Adequate Social Services for Suicidal Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident who expressed suicidal ideation (SI), leading to an attempted suicide. The resident, admitted in December 2023, had a history of bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Upon admission, the resident's hospital discharge paperwork noted SI, and a care plan was developed to address psychosocial well-being. However, the care plan did not specifically address the resident's history of SI. Despite a high score on the PHQ-9 indicating severe depression, the facility did not provide social services between the resident's admission and January 8, 2024. On January 8, 2024, the resident expressed a desire to die and fear of a staff member, which was reported to the unit manager and DON. The resident was later hospitalized for a planned procedure and returned to the facility on January 31, 2024. During the hospital stay, the resident again reported SI and was placed under observation. Despite this, the facility did not provide social services from January 31 to February 16, 2024. On February 16, the resident attempted suicide by tying a plastic bag around their neck and was sent to the hospital for evaluation. Interviews with the Social Services Assistant revealed that the resident had cognitive issues and struggled with adjusting to the facility. The assistant acknowledged that residents expressing SI should be monitored regularly and have an updated care plan. However, the facility relied on an outside contract service for social worker support, and the resident did not receive the necessary social services to address their SI and mental health needs.
Failure to Prevent Decline in Range of Motion and Implement Physician's Orders
Penalty
Summary
The facility failed to prevent a worsening of range of motion for Resident #125, who was admitted with diagnoses including dementia and diabetes. Upon admission, the resident did not have any impairments in range of motion according to the Minimum Data Set (MDS) and occupational therapy evaluation. However, subsequent observations revealed that the resident developed contractures in both hands, which were not present upon admission. The facility's nursing assessment later noted impairments in the resident's upper extremities, but no referral was made to rehabilitation for further evaluation and intervention. Interviews with staff, including a CNA, a nurse, and the unit manager, indicated a lack of awareness and communication regarding the resident's decline in range of motion. The facility also failed to implement a physician's order for a left hand resting splint for Resident #16, who was admitted with a left hand contracture and a history of traumatic brain injury. Despite the physician's order and care plan indicating the need for a resting hand splint, observations showed that the resident was not wearing the splint during multiple instances. The resident reported that staff did not assist with applying the splint, and a CNA confirmed that the splint was sometimes unavailable. Instead, a carrot device was used, which was not an appropriate substitute for the prescribed splint. Interviews with the unit manager and the DON confirmed that the resting hand splint should have been used, and any refusal by the resident should have been documented. The facility's policy on the prevention of decline in range of motion was not adhered to in both cases. For Resident #125, there was a failure to assess and refer the resident for therapy when a decline in range of motion was noted. For Resident #16, the facility did not ensure the implementation of the physician's order for a resting hand splint, and there was a lack of documentation regarding the resident's use or refusal of the splint. These deficiencies highlight a breakdown in communication and adherence to care protocols within the facility.
Failure to Complete Annual Employee Reviews
Penalty
Summary
The facility failed to complete annual reviews for five out of five employees whose personnel records were reviewed. On June 5, 2024, at 12:30 P.M., a surveyor examined the personnel records and found no indication that annual reviews were completed for any of the five employees in 2023. During an interview at 1:49 P.M. on the same day, the Director of Nursing confirmed that she was responsible for ensuring the completion of annual reviews and admitted that no reviews were conducted in the past year.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The Facility Assessment, updated in March 2024, indicated the need for competent support and care, including infection control and prevention. However, during interviews, it was revealed that the Director of Nursing (DON) had been covering the role of infection preventionist since April 2024 without the required infection control certification. The facility did not have an approved infection preventionist working in the facility. Interviews with the Medical Director and Administrator confirmed the absence of a designated infection preventionist. The Medical Director expected the facility to have an infection preventionist managing the infection control program, while the Administrator acknowledged the lack of one. Additionally, the Regional Nurse, responsible for the facility, could not provide details about the infection prevention program, further indicating the absence of a qualified infection preventionist.
Failure to Maintain Airborne Precautions and Report Communicable Disease
Penalty
Summary
The facility failed to maintain proper airborne precautions for a resident diagnosed with chickenpox. The resident, who had severe cognitive impairment, was observed walking in the hallway and interacting with staff without being encouraged to return to their room, despite being on airborne and contact precautions. Staff members, including a CNA and the Maintenance Director, were seen entering the resident's room without appropriate PPE, such as N-95 masks, and did not follow proper hand hygiene protocols. The facility's policy required residents on transmission-based precautions to remain in their rooms, but this was not enforced. Additionally, the facility did not conduct site-specific infection control surveillance and risk assessments in response to the active varicella outbreak. The infection control line listings for May and June 2024 lacked documentation of monitoring, tracking, and analyzing infections or implementing an outbreak investigation. The facility's Infection Preventionist did not maintain documentation of incidents or corrective actions, and there was no evidence of ongoing surveillance or follow-up activities related to the outbreak. Furthermore, the facility failed to report the communicable disease, varicella-zoster virus, to the local or state health department in a timely manner. The facility's policy required prompt reporting of outbreaks, but the Health Care Facility Reporting System report did not include documentation of the chickenpox case being reported. Interviews with the DON and Administrator revealed a misunderstanding of reporting requirements, as they believed that a single case did not need to be reported.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey. Medications with short expiration dates, such as fluticasone propionate, ipratropium bromide nasal solution, and various eye drops, were found opened and undated in multiple medication carts across different floors. Nurses interviewed during the survey confirmed that these medications should be dated when opened. Additionally, medications requiring refrigeration, like latanoprost eye drops, were not stored in the refrigerator as required. The survey also revealed that medication carts and cabinets were left unlocked and unattended, posing a security risk. On several occasions, medication carts on different floors were observed open and unattended, with nurses acknowledging that they should be locked when not in use. A medication cabinet behind the second-floor nurses' station was also found open and unattended. The Director of Nursing confirmed that all medications should be stored according to pharmacy directions and that medication carts and cabinets should be locked when unattended.
Failure to Provide Orientation to Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that agency nursing staff received proper orientation to the facility's operations, including medication administration procedures. This deficiency was identified through interviews, record reviews, and policy reviews. The facility's policy, revised in February 2023, mandates an effective orientation process for all contractual staff before they have formal contact with residents. However, the facility assessment from December 2022 did not specify how agency staff are trained to meet resident needs. On June 6, 2024, a surveyor observed a nurse attempting to administer incorrect medications, who later revealed that it was his first day and he had not received any orientation, including training on the medication administration software or process. Further investigation revealed that the orientation process was not consistently implemented. The Staff Development Nurse admitted that agency nurses should receive an orientation checklist before being given keys to a medication cart, but this was not always happening due to her limited work schedule. The Director of Nursing acknowledged a breakdown in the process, as evidenced by incomplete orientation checklists for agency nurses. A review of six agency nurse orientation checklists showed that five were incomplete, lacking necessary signatures or competency confirmations. Additionally, four agency nurses who worked on June 4 and 5, 2024, did not have any orientation checklists on file, indicating a systemic issue in the orientation process for agency staff.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in addressing their specific needs. Resident #192, who was admitted with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, had a history of suicidal ideation. Despite this, the facility did not create a care plan to address the resident's suicidal ideation, even after the resident expressed a desire to die and was readmitted following a hospitalization for suicidal ideation. Interviews with facility staff, including the Social Services Assistant, psych NP, and Director of Nursing, confirmed that a care plan should have been developed to ensure the resident's safety and provide supportive services. Resident #62, admitted with a stroke and left-sided hemiparesis, exhibited behaviors of chewing on items, which posed a choking risk. The facility's records did not include a care plan addressing these behaviors or interventions to prevent choking, despite observations and staff interviews indicating the resident's need for a chewing stick and the inappropriateness of a palm guard. The Unit Manager and Director of Rehab acknowledged the resident's behavior and the associated risks, yet the care plan lacked documentation of these interventions. The facility's policy on comprehensive care plans emphasizes the need for person-centered care plans that address residents' risks and needs. However, the facility did not adhere to this policy for Residents #192 and #62, resulting in a failure to provide adequate care planning for their specific conditions and behaviors. This oversight was identified through observations, record reviews, and staff interviews, highlighting the need for proper documentation and implementation of care plans to ensure resident safety and well-being.
Failure to Update Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to revise the behavioral health care plan for a resident after a comprehensive assessment and the expression of suicidal ideation. The resident, admitted in December 2023, had diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, and scored a 10 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. Despite the resident's history of suicidal ideation reported during a hospital stay, the facility did not update the care plan to address this risk. The initial care plan focused on psychosocial well-being but did not include specific interventions for suicidal ideation. The deficiency was further highlighted when the resident expressed a desire to die on January 8, 2024, and was readmitted to the facility on January 31, 2024, after a planned hospitalization for suicidal ideation. Despite these events, the care plan was not revised to include measures for managing suicidal ideation. Interviews with facility staff, including the Social Services Assistant, the psychiatric nurse practitioner, and the Director of Nursing, confirmed that the care plan should have been updated to include safety measures and supportive services for the resident's suicidal ideation.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform them independently. The resident, admitted in May 2024 with diagnoses including bipolar disorder and depression, was observed on two separate occasions with long, thick, bushy chin hair. The resident expressed a desire for assistance in removing the facial hair, but no such assistance was offered. The facility's policy on ADLs, reviewed in February 2023, mandates that residents unable to carry out ADLs should receive necessary services to maintain good grooming and personal hygiene. Interviews with facility staff revealed a lack of adherence to the care plan initiated for the resident, which required extensive assistance with personal hygiene. Certified Nursing Assistants (CNAs) acknowledged that they did not offer facial hair removal as part of the ADL care, despite it being a standard procedure. The Director of Nursing confirmed that chin hair removal is part of ADL care and should be documented if refused by the resident, which was not the case here. The medical record review showed no indication that the resident refused care, highlighting a deficiency in the facility's provision of required ADL assistance.
Medication Error Rate Exceeds 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 14.29% during the survey. This deficiency was observed when two out of three nurses made four errors out of 28 medication administration opportunities. The errors affected two residents, one of whom was administered the incorrect dosage of metoprolol and an incorrect substitute for a dietary supplement. The nurse involved was not familiar with the facility's procedures and attempted to administer two half tablets of metoprolol instead of the prescribed one half tablet, and substituted Rena Vite for Tab-a-vite without a physician's order. Another resident was affected when a nurse administered incorrect dosages of olanzapine and Zoloft. The nurse relied on the medication card instead of the physician's order in the computer, resulting in the administration of only half the prescribed dose of olanzapine and an incorrect dosage of Zoloft. The Director of Nursing confirmed that medications should be administered according to the physician's order in the computer, not based on the medication card.
Medication Administration Error Due to Lack of Orientation
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse prepared to administer double the prescribed dose of metoprolol, a medication used to lower blood pressure and heart rate. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had an active physician's order for 12.5 mg of metoprolol to be given twice a day. However, Nurse #14, who was unfamiliar with the facility and its medication administration software, prepared two half tablets of 12.5 mg each, intending to administer a total of 25 mg. The error was identified when the surveyor intervened and requested clarification of the metoprolol order. Nurse #14 admitted to not being oriented to the facility and was unaware of the correct dosage. Nurse #16 clarified that the order was for one half tablet of a 25 mg metoprolol tablet, equating to a 12.5 mg dose. The Director of Nursing confirmed that medications should be administered according to the physician's order, and Nurse #14 should have administered only one half tablet.
Failure to Address Hoarding of Hazardous Items by Resident
Penalty
Summary
The facility failed to ensure a safe environment for Resident #37, who was admitted with diagnoses including traumatic brain injury and schizophrenia, and was severely cognitively impaired. The resident exhibited behaviors of hoarding hazardous items such as razors, which were not addressed with appropriate interventions. On one occasion, the resident was found with approximately 20 razors and other items hidden in their room, which were discovered while the resident was on a medical leave of absence. Despite these findings, the facility did not implement interventions to monitor the resident's behavior upon their return. Further incidents occurred, including the resident cutting off a wander guard device and hoarding additional hazardous items like nail clippers and metal silverware. Although a physician's order was eventually put in place for daily safety checks, these were not initiated until after the resident was noted to be cutting off their wander guard. Interviews with staff revealed that routine searches of the resident's room were not conducted until after a significant incident where the resident threatened to harm their roommate.
Improper Management of Urinary Catheter Devices
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident with severe cognitive impairment and an indwelling urinary catheter. The resident, who was admitted with diagnoses including obstructive uropathy and chronic kidney disease, was observed multiple times with the urinary catheter drainage bag and tubing directly touching the floor. These observations occurred over several days, indicating a consistent failure to ensure proper placement of the catheter drainage system. Interviews with facility staff, including a CNA, Nurse Supervisor, and the Director of Nursing, confirmed that the urinary catheter drainage bag and tubing should not touch the floor to prevent infection. Despite this understanding, the staff did not consistently prevent the drainage bag and tubing from coming into contact with the floor, even though the resident was dependent on staff for bed mobility and unable to adjust the bed height independently. This oversight in care practices contributed to the deficiency identified by the surveyors.
Failure to Provide Emergency Dialysis Equipment at Bedside
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring renal dialysis. The deficiency was identified when it was observed that emergency clamps and pressure dressing, which were supposed to be kept at the bedside for a resident with a central venous catheter for dialysis, were missing. This was contrary to the facility's policy and the resident's care plan, which specified that clamps should be available at all times for emergency use. The resident in question was admitted with acute kidney failure and type 2 diabetes mellitus with diabetic chronic kidney disease. Despite the care plan and medical orders indicating the necessity of having clamps at the bedside, observations on two separate occasions confirmed their absence. Interviews with the unit manager, a nurse, and the Director of Nursing corroborated that the clamps and pressure dressing should have been present in the resident's room, highlighting a lapse in adherence to the established care protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, admitted in June 2021, was identified as having severe cognitive impairment and an active diagnosis of PTSD. Despite these conditions, a review of the resident's medical record revealed that no care plan addressing PTSD had been developed or implemented. The facility's policy on 'Trauma Informed Care', reviewed in February 2023, mandates that care and services should be culturally competent and address the needs of trauma survivors. This includes minimizing triggers and re-traumatization, and collaborating with residents and staff in developing care plans. During an interview, the Director of Nursing stated that social services are responsible for creating PTSD care plans, and confirmed that any resident with a PTSD diagnosis should have such a plan in place.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that their clothing adequately covered sensitive body parts. The resident, who was admitted in September 2021 with diagnoses of major depression and schizophrenia, was observed walking in the hallway with ripped sweatpants that exposed their buttocks. This occurred despite the resident having a severe cognitive impairment, as indicated by a BIMS score of 7 out of 15, and requiring supervision with bathing and dressing tasks. During the observation period, the resident walked past a nurse several times and interacted with a CNA, yet no action was taken to address the inappropriate clothing. The resident's ADL care plan, last revised in May 2024, indicated a need for maximal assistance with dressing, and CNA documentation confirmed the resident required substantial assistance for lower body dressing on the day of the incident. The Director of Nursing acknowledged that staff should have encouraged the resident to change into appropriate clothing.
Failure to Address Chirping Fire Alarm in Resident's Room
Penalty
Summary
The facility failed to provide a homelike environment by not addressing a chirping fire alarm in a resident's room. This deficiency was observed over three consecutive days, with the fire alarm in the specified room continuously chirping. Despite the persistent issue, the Maintenance Director was unaware of the problem, as he relies on maintenance logbooks or direct phone calls from staff to be informed of such issues. The lack of communication and notification to the Maintenance Director resulted in the unresolved chirping fire alarm, contributing to the failure in maintaining a comfortable and homelike environment for the resident.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy concerning resident-to-resident abuse, specifically involving a resident with a history of traumatic brain injury, schizophrenia, and traumatic hemorrhage of the cerebrum. This resident, who was admitted in September 2023, was assessed as severely cognitively impaired, scoring 6 out of 15 on the Brief Interview for Mental Status Exam. On January 22, 2024, the resident made homicidal comments and was subsequently involuntarily hospitalized after resisting police intervention. The psychiatric nurse practitioner noted that the resident had become agitated and made threats to harm their roommate. Despite the facility's policy requiring immediate investigation and reporting of such incidents, the state agency's reporting system showed no record of the incident being reported. The Director of Nursing, during an interview, expressed unawareness that the incident had not been reported, indicating a lapse in following the established procedures for reporting abuse or threats of abuse to the appropriate authorities.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving a resident with a history of traumatic brain injury, schizophrenia, and traumatic hemorrhage of the cerebrum. The resident, who was severely cognitively impaired, made homicidal comments and threatened to strangle their roommate. Despite the severity of the incident, the facility did not report it to the state agency as required by their Abuse, Neglect, and Exploitation policy. The incident occurred when the resident became agitated and shouted during an interaction with a psychiatric nurse practitioner. The resident's threatening behavior led to their removal from the facility by emergency services. However, a review of the state agency's reporting system showed no record of the incident being reported. The Director of Nursing was unaware that the incident had not been reported, indicating a lapse in the facility's reporting procedures.
Failure to Update PASARR for Resident with Mental Disorders
Penalty
Summary
The facility failed to obtain an updated Pre-Admission Screening and Resident Review (PASARR) for a resident who was admitted with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Upon admission, the resident scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident had a PASARR Level II completed, which allowed for a Provisional Emergency admission to the nursing facility not to exceed 7 calendar days. However, the facility did not provide evidence of completing an additional PASARR Level II review, despite the resident's stay exceeding the 7-calendar day limit.
Failure to Provide Correct Therapeutic Diets
Penalty
Summary
The facility failed to provide the correct ordered therapeutic diet for two residents, leading to a deficiency in dietary management. Resident #40, who has severe cognitive impairment and dysphagia, was observed multiple times consuming regular textured foods such as toast, whole grapes, and sausage links, despite having a physician's order for a ground texture diet. The dietary orders and meal tickets indicated a need for a mechanically altered diet, but these were not adhered to, as confirmed by interviews with staff, including a CNA, a nurse, and the Speech Language Pathologist (SLP). The SLP emphasized that Resident #40 should not consume whole or regular textured foods due to the risk associated with his/her condition. Similarly, Resident #45, who also has severe cognitive impairment and difficulty swallowing, was observed eating regular textured foods like whole toast, sausage links, and a blueberry muffin. Despite a physician's order for a ground texture diet due to swallowing difficulties, these orders were not followed. The SLP confirmed that Resident #45 was downgraded to a ground diet and should not be eating whole foods. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of adherence to dietary orders, as meal trays were not checked to ensure compliance with the prescribed diet. The deficiency was further highlighted by the inconsistency in staff understanding and implementation of dietary orders. While some staff members acknowledged the need for a ground diet, others, including a supervisor, incorrectly stated that certain foods were permissible. The DON confirmed that all meal trays should be checked by a nurse to ensure the correct diet is provided, but this protocol was not followed, leading to the dietary management failure for both residents.
Deficiency in Behavioral Health Services for Residents with Depression
Penalty
Summary
The facility failed to accurately evaluate their resident population and identify the necessary resources to provide adequate behavioral health services. The facility's assessment, revised on March 19, 2024, claimed the ability to manage medical conditions and medication-related issues causing psychiatric symptoms and behaviors. It also stated the facility could implement interventions for residents dealing with anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. However, during the survey, it was found that out of 68 residents identified with depression disorder, 6 residents did not receive the necessary behavioral health services after a decreased mood was identified through the PHQ-9, a tool used to measure depression.
Failure to Accurately Document and Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with a left hand contracture and a history of traumatic brain injury. The resident was supposed to wear a resting hand splint on the left hand as per the physician's order and the plan of care. However, the Treatment Administration Record (TAR) inaccurately documented that the splint was applied on specific dates, while observations by the surveyor revealed that the resident was not wearing the splint during those times. The resident expressed that staff did not assist in putting on the splint despite requests. Further investigation revealed that a Certified Nurse Assistant (CNA) applied a different device, a carrot, which was not a substitute for the prescribed resting hand splint. The Unit Manager and the Director of Nursing confirmed that the resident should have been wearing the resting hand splint and that any refusal by the resident should have been documented in the TAR or progress notes. However, there was no documentation indicating that the resident had refused to wear the splint.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light was accessible for a resident, leading to a deficiency. The resident, admitted in December 2021, had diagnoses including dementia, cerebrovascular accident (stroke), and depression, and was assessed to have intact cognition. The resident required assistance with bathing, dressing, and transfers. On multiple occasions, the surveyor observed the resident in bed with the call light inaccessible and out of reach, lying on the floor behind the bed. The resident confirmed the inability to call for help or assistance. The resident's fall care plan, dated March 2024, included an intervention to ensure the call light was within reach, which was not adhered to. During an interview, a unit manager acknowledged that call lights should be within reach and accessible for all residents.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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